Correction: Time course change of the insulin requirements during the perioperative period in hepatectomy and pancreatectomy by using an artificial pancreas STG-55.

[This corrects the article DOI: 10.1007/s13340-023-00623-3.].

Time course change of the insulin requirements during the perioperative period in hepatectomy and pancreatectomy by using an artificial pancreas STG-55.

Introduction: To investigate changes in insulin requirements over time in patients who underwent hepatectomy and pancreatectomy with perioperative glycemic control by an artificial pancreas (STG-55). Materials and methods: We included 56 patients (22 hepatectomies and 34 pancreatectomies) who were treated with an artificial pancreas in the perioperative period and investigated the differences in insulin requirements by organ and surgical procedure. Results: The mean intraoperative blood glucose level and total insulin doses were higher in the hepatectomy group than in the pancreatectomy group. The dose of insulin infusion increased in hepatectomy, especially early in surgery, compared to pancreatectomy. In the hepatectomy group, there was a significant correlation between the total intraoperative insulin dose and Pringle time, and in all cases, there was a correlation with surgical time, bleeding volume, preoperative CPR, preoperative TDD, and weight. Conclusions: Perioperative insulin requirements may be mainly dependent on the surgical procedure, invasiveness, and organ. Preoperative prediction of insulin requirements for each surgical procedure contributes to good perioperative glycemic control and improvement of postoperative outcomes.

The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection.

BACKGROUND: Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR. METHODS: Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups. RESULTS: Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001]. CONCLUSION: M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

Outcomes of lung metastasis from pancreatic cancer: A nationwide multicenter analysis.

BACKGROUND: Although distant metastasis from pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, some single center studies reported that lung metastasis has a favorable prognosis. The aim of this study is to evaluate the prognostic value of site-specific metastasis after pancreatectomy for PDAC, with a focus on lung metastasis. METHODS: Data from 117 cases of lung metastasis after pancreatectomy were collected retrospectively from 23 institutions in Japan. To compare the sites of metastasis we also collected the data of 134 patients with liver only metastasis, 67 patients with peritoneal only metastasis and 121 patients with locoregional recurrence alone. RESULTS: In patients with lung only metastasis, the median time from recurrence to death (RTD) was 23.1 months, which was better in comparison to other sites of recurrence. In lung metastasis group, the patients who underwent pulmonary resection had better long-term outcomes in comparison to those who did not. (RTD: 29.2 vs 15.2, P < .001). In the multivariate analysis, solitary metastasis (HR 5.03; 95% CI 1.195-21.144, P = .022) and postoperative chemotherapy (HR 14.089; 95% CI 1.729-114.77, P = .023) were identified as significant prognostic factors after lung resection. CONCLUSIONS: Surgical resection is a favorable option for selected patients with a solitary lung metastasis and for whom adjuvant chemotherapy can be administrated.

Efficacy of surgical management for recurrent intrahepatic cholangiocarcinoma: A multi-institutional study by the Okayama Study Group of HBP surgery.

BACKGROUND: The prognosis of intrahepatic cholangiocarcinoma (ICC) has been poor, because of the high recurrence rate even after curative surgery. This study aimed to evaluate the prognostic impact of surgical resection of recurrent ICC. PATIENTS AND METHODS: A total of 345 cases of ICC who underwent hepatectomy with curative intent in 17 institutions were retrospectively analyzed, focusing on recurrence patterns and treatment modalities for recurrent ICC. RESULTS: Median survival time and overall 5-year recurrence-free survival rate were 17.8 months and 28.5%, respectively. Recurrences (n = 223) were classified as early (recurrence at ≤1 year, n = 131) or late (recurrence at >1 year, n = 92). Median survival time was poorer for early recurrence (16.3 months) than for late recurrence (47.7 months, p<0.0001). Treatment modalities for recurrence comprised surgical resection (n = 28), non-surgical treatment (n = 134), and best supportive care (BSC) (n = 61). Median and overall 1-/5-year survival rates after recurrence were 39.5 months and 84.6%/36.3% for surgical resection, 14.3 months and 62.5%/2.9% for non-surgical treatment, and 3 months and 4.8%/0% for BSC, respectively (p<0.0001). Multivariate analysis identified early recurrence, simultaneous intra- and extrahepatic recurrence, and surgical resection of recurrence as significant prognostic factors. In subgroup analyses, surgical resection may have positive prognostic impacts on intra- and extrahepatic recurrences, and even on early recurrence. However, simultaneous intra- and extrahepatic recurrence may not see any survival benefit from surgical management. CONCLUSION: Surgical resection of recurrent ICC could improve survival after recurrence, especially for patients with intra- or extrahepatic recurrence as resectable oligo-metastases.

Impact of Body Mass Index on Survival of Pancreatic Cancer Patients in Japan.

The impact of body mass index (BMI) on postoperative survival in Japanese patients with pancreatic cancer is unclear. We examined the relationship between preoperative BMI and the prognosis of Japanese patients who underwent surgery for pancreatic cancer to determine whether BMI affects these patients' prognosis. Of the patients who underwent pancreatectomy between January 2004 and August 2015 at our institution, 246 were pathologically diagnosed with pancreatic tubular adenocarcinoma; the cancer was located in the pancreatic head (n=161) and in the body and tail (n=85). We classified the patients by BMI: underweight (n=22), normal weight (n=190), and overweight/obese (n=34) groups. We retrospectively analyzed medical records for patient characteristics, lesion location, disease stage, postoperative complications, chemotherapy, and prognosis. Lesion location, disease stage, postoperative complications, and chemotherapy were not significantly different among the BMI groups. The median survival times were as follows (days): all patients, 686; underweight, 485; normal weight, 694; and overweight/obese, 839. In a multivariate analysis, after adjusting for competing risk factors, low BMI was associated with an increased risk of death (normal weight: HR 0.58, p=0.038; overweight/obese: HR 0.54, p=0.059). High BMI was not found to be a postoperative factor for poor prognosis in Japanese pancreatic cancer patients.

Modified Blumgart anastomosis with the "complete packing method" reduces the incidence of pancreatic fistula and complications after resection of the head of the pancreas.

BACKGROUND: Postoperative pancreatic fistula (POPF) and its complications remain problems. This study evaluated combination treatment with modified Blumgart anastomosis and an original infection control method (complete packing method) following pancreatic head resection. METHODS: This study included 374 consecutive patients who underwent pancreatic head resection: 103 patients underwent Cattell-Warren anastomosis (CWA); 170 patients underwent modified Kakita anastomosis (KA); and 101 patients underwent modified Blumgart anastomosis with the complete packing method (BAC). The outcomes of the KA and BAC groups were compared statistically. RESULTS: The POPF rate was significantly lower in the BAC group than in the KA group (28.8% vs 2.97%; p < 0.01). The overall postoperative complication rate, including SSI and postoperative hemorrhage, was significantly lower in the BAC group. CONCLUSIONS: The combination of modified Blumgart anastomosis and the complete packing method is a simple and useful method for reducing the incidence of POPF and postoperative complications.

Novel contrast-injection protocol for high-resolution abdominal CT-angiography: vascular visualization improvement with vasodilator.

PURPOSE: To evaluate the usefulness of a novel contrast-injection protocol for high-resolution abdominal computed tomography angiography (CTA) using nitroglycerin (NTG). METHODS: Abdominal CTA was performed in 80 patients using two 64-detector-row CT scanners. Forty patients were examined after administration of sublingual NTG (NTG group), while 40 were examined without NTG administration (non-NTG group). Arterial phase images were acquired with maximum intensity projection and volume rendering. Reduction rates: vessel cross-sectional areas ratio of 10 cm distal to origin at the superior mesenteric artery, contrast enhancements, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were assessed. Three reviewers evaluated degree of depiction of the peripancreatic vasculature using a four-point scale (1 = poor, 4 = excellent). RESULTS: Reduction rates were significantly lower in the NTG group (P < 0.001), while there were no significant differences in contrast enhancements, SNR, or CNR between groups. Visual evaluation results of the NTG group were significantly better than those of the non-NTG group (P < 0.01). CONCLUSION: Abdominal CTA using NTG improved visualization of the abdominal peripheral vessels. This improved arterial view may be beneficial for preoperative evaluation of the arterial anatomy.

Intra-Aortic Balloon Occlusion (IABO) may be useful for the management of secondary aortoduodenal fistula (SADF): A case report.

INTRODUCTION: Secondary aortoduodenal fistula (SADF) is a rare but life-threatening complication after aortic reconstruction. Although a number of reports describing treatments for SADF have been published, the optimal management is unclear. A review of the literature suggested methods of reconstruction, control of bleeding, and reduction of infection in the management of SADF. The most important factor for acute intervention is controlling the bleeding from the fistula. We report one case treated using intra-aortic balloon occlusion (IABO) for SADF. PRESENTATION OF A CASE: We describe a case of secondary aortoduodenal fistula that occurred seven years following aortobifemoral reconstruction for abdominal aortic aneurysm. DISCUSSION: Early control of bleeding is essential for survival of the patient. Emergency laparotomy or endovascular stenting frequently have been chosen as interventions, although each approach has significant limitations. Emergency laparotomy for patients with hemodynamic instability may create excessive physiologic stress, and endovascular stenting may not be available at every surgical facility. The use of IABO for cases of intraperitoneal bleeding due to trauma has been previously described. IABO is relatively easy to implement, and enabled us to control the bleeding from the aorta more rapidly than other strategies. CONCLUSION: Based on a review of the literature and our own experience, IABO should be considered as one option for the management of SADF.

Hereditary Spherocytosis in a Middle-aged Man Complicated with Common Bile Duct Stones.

Hereditary spherocytosis is the most common form of hemolytic anemia and is characterized by spherical, osmotically fragile erythrocytes that are selectively trapped by the spleen. Hereditary spherocytosis is typically diagnosed in childhood. We herein experienced a rare case of hereditary spherocytosis diagnosed in middle age. The patient presented with cholelithiasis and hyperbilirubinemia. He had no anemia and was asymptomatic with mild splenomegaly. In the differential diagnosis of these symptoms, the possibility of hereditary spherocytosis should be considered, even in patients who are middle-aged and lack anemia.

Metallic stent insertion with double-balloon endoscopy for malignant afferent loop obstruction.

Progress in double-balloon endoscopy (DBE) has allowed for the diagnosis and treatment of disease in the postoperative bowel. For example, a short DBE, which has a 2.8 mm working channel and 152 cm working length, is useful for endoscopic retrograde cholangiopancreatography in bowel disease patients. However, afferent loop and Roux-limb obstruction, though rare, is caused by postoperative recurrence of biliary tract cancer with intractable complications. Most of the clinical findings involving these complications are relatively nonspecific and include abdominal pain, nausea, vomiting, fever, and obstructive jaundice. Treatments by surgery, percutaneous transhepatic biliary drainage, percutaneous enteral stent insertion, and endoscopic therapy have been reported. The general conditions of patients with these complications are poor due to cancer progression; therefore, a less invasive treatment is better. We report on the usefulness of metallic stent insertion using an overtube for afferent loop and Roux-limb obstruction caused by postoperative recurrence of biliary tract cancer under short DBE in two patients with complexly reconstructed intestines.

A solid pseudopapillary neoplasm without cysts that occurred in a patient diagnosed by endoscopic ultrasound-guided fine-needle aspiration: a case report.

INTRODUCTION: Solid pseudopapillary neoplasm of the pancreas is a rare neoplasm that has been reported to account for between 0.17% and 2.7% of all non-endocrine tumors of the pancreas. It is usually seen in young women. Because solid pseudopapillary neoplasms are rarely aggressive and have low-grade malignant potential and an excellent prognosis after complete resection, it is an ideal pancreatic tumor for treatment by minimally invasive surgery. Therefore, making an accurate pre-operative diagnosis is very important. CASE PRESENTATION: A 24-year-old Japanese man who had been found to have mild transaminase elevations at a medical check-up visited our hospital for further examination. Abdominal computed tomography showed a 40mm-diameter tumor in the pancreatic tail and mild fatty liver. He was admitted to our hospital for additional examination. The abdominal contrast-enhanced computed tomography scan taken at our institution showed an increasingly enhanced mass of 40mm diameter in the pancreatic tail. Ultrasonography showed a low-level echoic mass of 35mm diameter in the pancreatic tail. T1-weighted magnetic resonance imaging showed low signal intensity in the tail of the pancreas. T2-weighted magnetic resonance imaging showed high signal intensity there. Diffusion magnetic resonance imaging showed high signal intensity. An endoscopic ultrasound yielded the same results as the abdominal ultrasonogram. In addition, [18F]-fluorodeoxyglucose positron emission tomography/computed tomography showed abnormal accumulation (maximum standardized uptake value, 6.53). This finding raised our suspicion of a pancreatic malignant tumor. However, the patient could not be confidently diagnosed solely on the basis of imaging. Endoscopic ultrasound-guided fine-needle aspiration was performed, which led us to a diagnosis of solid pseudopapillary neoplasm. On that basis, we performed minimally invasive surgery (spleen-preserving laparoscopic distal pancreatectomy). CONCLUSION: Atypical solid pseudopapillary neoplasm without cysts should be considered when diagnosing pancreatic tumors. A definitive pre-operative diagnosis of solid pseudopapillary neoplasm made on the basis of endoscopic ultrasound-guided fine-needle aspiration can guide the surgical approach used.

A case of follicular cholangitis mimicking hilar cholangiocarcinoma.

Follicular cholangitis is a sclerosing cholangitis with hilar biliary stricture that must be differentiated from both immunoglobulin G4-related sclerosing cholangitis and primary sclerosing cholangitis. This disorder is extremely rare and difficult to distinguish from hilar biliary cholangiocarcinoma. We report here a case of a Japanese female patient in her 60s with this disease. The patient visited a family doctor for itching and general fatigue. Blood examination showed elevated hepatobiliary enzyme levels. Various imaging studies showed dilation of the bilateral intrahepatic bile duct and wide stenosis from the proximal bile duct to the right and left hepatic duct. They also showed the enlargement of multiple lymph nodes in the hepatoduodenal ligament, periaorta, and mesocolon. Based on endoscopic retrograde cholangiopancreatography-directed brush cytology, we diagnosed this patient with hilar cholangiocarcinoma and performed left trisegmentectomy of the liver. The pathology results showed that the wall from the bilateral hepatic duct to the proximal bile duct had thickened irregularly with dense fibrosis and a marked formation of lymph follicles. The mucosal epithelia did not have malignant findings. The diagnosis was follicular cholangitis. This case indicates that follicular cholangitis should be considered as a differential diagnosis of hilar biliary stricture.

[A case of a patient who underwent resection of the remnant pancreatic cancer following a distal pancreatectomy for invasive ductal carcinoma].

Herein, we report the case of a patient who underwent resection of the remnant pancreas for pancreatic cancer following a distal pancreatectomy for invasive ductal carcinoma. An 81-year-old woman underwent a distal pancreatectomy. The tumor was found to be pancreatic cancer. The tumor was histologically diagnosed as a poorly differentiated tubular adenocarcinoma (Stage I). An abdominal computed tomography (CT) performed 17 months later revealed a 13 mm tumor in the remnant pancreatic head. A remnant pancreatectomy was performed. The histological diagnosis was a moderately differentiated tubular adenocarcinoma (StageIII). Remnant pancreatic cancer is rare following a pancreatectomy for invasive ductal carcinoma. The course of remnant pancreatic cancer can be followed with imaging. Long-term follow-up of patients who have undergone a pancreatectomyis, therefore, essential.

Diagnosis of a solid pseudopapillary neoplasm using EUS-FNA.

A woman in her 50s was found to have a pancreatic mass on abdominal ultrasound. The tumor measured 40 mm in diameter and included a cystic lesion and calcification. In this case, we suspected a diagnosis of solid pseudopapillary neoplasm (SPN) due to the findings observed on various images. However, we were unable to exclude the possibility that the lesion was a neuroendocrine tumor. Therefore, we performed endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA). In addition, in order to confirm the diagnosis of SPN, we performed minimized resection (segmental pancreatectomy). Obtaining a definitive preoperative diagnosis of SPN using EUS-FNA can guide the surgical approach.

[A case report of successful control of liver metastasis from duodenal cancer with combined S-1 and docetaxel chemotherapy].

A 70-year-old man with abdominal pain and anemia was diagnosed with duodenal cancer upon upper gastrointestinal endoscopy and biopsy. Pancreatoduodenectomy was performed. Pathological findings were duodenal cancer, T 4 SI (Panc) N0P0V0A0H0. Three months after operation, abdominal CT showed multiple liver metastasis. He then underwent combined chemotherapy consisting of two weeks administration of S-1 (80 mg/body) followed by one week rest and injections of docetaxel (40 mg/body) every three weeks as one course. Metastatic tumors were gradually reduced and successfully controlled,and there was no other recurrence until he died about three years later of another illness. Combined S-1 and docetaxel chemotherapy is known to be effective for esophageal cancer, gastric cancer and other digestive cancer, as well as for duodenal cancer.

Adjuvant arterial infusion chemotherapy after resection of hepatocellular carcinoma with portal thrombosis: a pilot study.

BACKGROUND/PURPOSE: The prognosis of hepatocellular carcinoma (HCC) with tumor thrombosis of the main trunk or major branches of the portal vein (mPVTT) is extremely poor, even if it is curatively resected. Uncontrollable multiple metastases to the residual liver are often observed within several months after the operation. We report here the results of a pilot study, showing the efficacy of adjuvant arterial infusion chemotherapy after the resection of HCC with mPVTT. METHODS: Twelve patients had curative resection of HCC with mPVTT. Six of the patients were treated by the arterial infusion of a chemotherapeutic agent via a subcutaneously implanted injection port after curative resection of HCC with mPVTT. The initial course consisted of the daily administration of cisplatin (CDDP) and continuous infusion of 5-fluorouracil (5-FU). This was followed by the weekly or biweekly administration of CDDP and subsequent infusion of 5-FU until the cumulative dose of 5-FU reached 15 g. RESULTS: The median overall survival time was 58.0 months with adjuvant chemotherapy and 8.0 months without adjuvant chemotherapy. The median disease-free interval was 15.0 months with adjuvant chemotherapy and 4.0 months without adjuvant chemotherapy. Adverse reactions were tolerable nausea and loss of appetite. CONCLUSIONS: This chemotherapeutic regimen achieved favorable results and may be useful as adjuvant chemotherapy in treating patients after curative resection of HCC with mPVTT.